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FEB-13y 2012�14:48 From: To:+9522494616 P.3�3
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<br /> �'� City of Orono
<br /> uilding Permit Application for Internal Wo�k
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Addross: Q�
<br /> '��,0,�`� PO Box 66 Permit nurnbe�:
<br /> �� Q\1 Crystal Bey,MN�5323-OOC.G I�ate received' �-�
<br /> �I � ' ,
<br /> 1� � , �� ,Strar3tAr/d��.c: Aeceived by:
<br /> \� `. 27G(1 K911ey Parkway Pla�review fd ' —
<br /> �� Orono,MN 55356 ��`
<br /> ���o�� �" / a2 5Ld. /
<br /> -=-' 'I ow�Fee:
<br /> 0
<br /> Main: 952-zdg.a600 Fax: 452-249-a6t6 www.ci.orono.mn.us / .
<br /> �� This appliaedon fnrn►rnu�t be completed in full and all required informatbn musc be submitted.
<br /> Incomplete appllcallons will 6a retumed. (Please prinf)
<br /> GENERAL INF4RMATION: � _� + �
<br /> Job Sfte/Wdress: �.�'7C7 � � -W r� S�O�E�:'iu
<br /> Wllt thls be a P�radc of l�omes, Remodalers S owcase Ho r othrt Displsy H e? es No
<br /> _ 1f y�,,�.kP4ci�!a�n�pe�lnU IR naquinCd wffh Poliae Deparfrnenf and C.�Tr GvunCil appruv;Jl 60 dvys pau w tAe eYeru.�ShuGfle 6us vo 'rn will.,de .•
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<br /> r:.r:- _ riequlrcd u�ik�s appNcanl deinonsvaroa suliciant on-aBe pnrking is oveHebk. NOA-OC�1fld CVMl�t WNI►W�b�a�UOWeKL ,
<br /> CONTRACTOR!AP�LeCANT IN�RMATION:
<br /> Nama: L.'1 r�pn.�e �
<br /> State License�i o Expiration Dete:
<br /> �ead Certification Num r� � �. Expiration Date.
<br /> (foi work oe ho►nes t t were con9fnicte priar to 1978 - -
<br /> Phone: (' (otficel I - $�—32, ]___. (cell)
<br /> Mailing Address: , . [�,,Q�: 1 b City ;,� ZIP:
<br /> Contact Person' � Applical�t ig: : .�� Ir� r komeownCr �crca o�a�
<br /> Emeil�and/or.1"ax: - � : � .. ,_ � �
<br /> PROP�RTY OWNER I FORMA710N: J .
<br /> Name:' � �..�.Y��� Y� re �tP_v+.T' b�tL��-..
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<br /> Phone'�day): - � � ' _ ' .
<br /> AddFess: ��-Q, l.�' Y`' "'�;' City. ' � ZIP, �I� i
<br /> Ema�andlar Fax �,�niflh ��yy�p,1- _ ��rr,�rry�_t,l�� �� L� ' w`
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<br /> PROJECT INFORMATION: � �
<br /> Type of PtoJect � � � Amr sirth movemerit may re uire
<br /> i { � s�,,,
<br /> I ' � MCWD rcvlrw a Re�mp :
<br /> �DODf(Sj ; �0 Rerr►ode� ❑Wster Da�maqe I,Alnnrhahe Creek WatEr,had Distri t MCWD
<br /> �� ;; �: , :�, t >
<br /> Q�p{v,'ndraw(3�. ' ❑Repair . 0 F.tornn Damege 182(►7.Minnelonka Blvci
<br /> fiitlin ❑RPsto►ation �1Cc��aven,MN S5.3s1
<br /> O` 8 : � D om��(sneury) Pno��_ �r2-���-o�eo
<br /> V Re-roof '� Fire Damage Fax: 852�7�-0682
<br /> ��p;,�;s„ , � , ,; ,rninnehahac ek. r
<br /> � ' 11 Project Descril tion� � , _ .. .._ . ,
<br /> E �irt»tod Co�structl n Valuatio�of Project.�excludlny land) � O C7 .O••-
<br /> �;'it. �``''_ - - -�-- -- -
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<br /> AP�►LICANT ACKNO I�EDGEMENT:
<br /> , .. .. ... ...— ...
<br /> Ag�eE to proviAF;�II information rr,qi iined nr►r3quested by tha Builditl�0A[�rtment; '
<br /> �,;� 'C�ertlfies that the nforri�aUon supplled is true and correct to Ihe best o1 his/her kn�w►t;d�e. TFte�pphcnn�m ii�s that they (
<br /> pr�C solely respon ible,For submiUing a complei�BppIiCBUan belr���w�are tF1at upon f�ilurc to do�6; me st�ft ha no altern�l�ve �
<br /> -'' :.bUCto�eject il ut� I il i5 Com���ete:
<br /> �.;, ''�,c�md ur all of In Inform�it�pn lhat you ere ysked w proviCe on this aapllca6o� �s cJa�:siNwd by&tata law as Iher pr'Nate or
<br /> Y�� ?" c`vnUOenlial- Pri �0dle'Is mlormatiun which generally cannot be giver+ l0 1he DUbllc t�ut can he given to ch subject ot ihe
<br /> '-' "`� data. Conficlt,nti I rlata is:infornK',lfon which generaly can�ot bw gi�ren to ehher tt�r, puhtk ar 1he subJecl of Ihe tlata. Ow�
<br /> -'"�c>+�.,, r��,,rp�ars �n�1 in�ce��e�.i ►�ea nf rhis informatian IS tn annuatly update our rocords and rscords ot�olher g�vem� ntal ayenc�as
<br /> , ; - , reauired bv I.aw. _�t, �► Ge to s, „ I ,th�infonnallon,tha appfication may no!be issued.
<br /> e.� 4PF?!+ _ — . .._..�
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<br /> kpplic�nCs Signature: ..: _, _„ Data: ; _ �,; .
<br /> i,��s,u��uA�: aa-�i-�n7� ;
<br /> I Id � JI�. . .� !.. _. , . . . .. , . . . . .. ,.. .
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